Provider Demographics
NPI:1861482010
Name:DER, EDISON HONG (DDS)
Entity Type:Individual
Prefix:
First Name:EDISON
Middle Name:HONG
Last Name:DER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:148 N GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91791-1728
Mailing Address - Country:US
Mailing Address - Phone:626-858-3305
Mailing Address - Fax:626-858-3306
Practice Address - Street 1:148 N GRAND AVE
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91791-1728
Practice Address - Country:US
Practice Address - Phone:626-858-3305
Practice Address - Fax:626-858-3306
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA247681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice